Oral pulsed high-dose dexamethasone for myositis

Pain in autoimmune inflammatory myopathies: a scoping review

BACKGROUND

Pain is considered a priority for research by adult patients with autoimmune inflammatory myopathy (AIM) and their families. Our aim was to review the literature for studies reporting on pain in adult AIM and to summarise their findings.

METHODS

A scoping review was conducted searching for studies in PubMed and MEDLINE including more than five adult patients with AIM and assessing pain using a patient-reported outcome measure. Study population characteristics, pain measurement and clinical correlates of pain were extracted using a standardised protocol.

RESULTS

The search strategy identified 2831 studies with 33 meeting inclusion criteria. Most studies used visual analogue scales (n=14) and/or the Medical Outcomes Study 36-Item Short Form Bodily Pain Scale (n=17). Frequency of pain and/or myalgias ranged from 64% to 100%. Subjects with AIM had significantly more pain than the general population and comparable pain to other chronic rheumatic diseases. Insufficient results were available to identify significant clinical correlates of pain in AIM.

CONCLUSION

This review suggests that the burden of pain in AIM is considerable. Still, due to the heterogeneity and low quality of the evidence, significant knowledge gaps persist. Studies are needed to characterise pain trajectories of patients with AIM.

Treatment of the inflammatory myopathies: update and practical recommendations

BACKGROUND

The inflammatory myopathies are a heterogeneous group of diseases including dermatomyositis, polymyositis, and inclusion body myositis. Clinical trials in myositis are rare, making it difficult to make clear recommendations on the treatment of these rare disorders.

OBJECTIVE

To give an overview of treatment options and strategies and to provide the clinician with a framework that can be used in treating patients with myositis.

METHODS

Results of clinical trials in myositis, case series and important case reports are presented and discussed.

RESULTS/CONCLUSION

Most patients with dermatomyositis or polymyositis require treatment with oral high-dose prednisone combined with azathioprine or methotrexate to facilitate early tapering of prednisone. In case of treatment failure, intravenous immunoglobulin can be tried, followed by rituximab, mycophenolate mofetil, or tacrolimus depending on the specific clinical situation. A treatment trial with oral prednisone combined with methotrexate is advised in a subgroup of patients with inclusion body myositis.

Technology Insight: tools for research, diagnosis and clinical assessment of treatment in idiopathic inflammatory myopathies

Idiopathic inflammatory myopathies, known collectively as myositis, are chronic diseases that cause disability, mainly from muscle weakness, despite the use of immunosuppressive therapies. An improved outcome requires increased knowledge of the key molecular pathways that cause symptoms in muscles and other organs. Technological advances offer promise for improving our understanding of disease mechanisms, and some tools will be helpful in diagnosis and the assessment of therapeutic success. The application of new tools depends on their validation in longitudinal studies using clinical outcome measures combined with assessments of molecular events in affected organs. Clinical outcome measures and definitions of improvement have been developed and validated through the International Myositis Assessment and Clinical Studies collaboration. Some imaging techniques, such as MRI and magnetic resonance spectroscopy of muscles, and high-resolution CT of lungs, can assess changes in local inflammatory activity, among many other aspects of pathology. Changes in protein and gene expression patterns in repeated biopsies from affected organs (muscle, skin and lungs) provide molecular information and allow increasingly precise disease classifications and therapeutic evaluation, but are to date only research tools. This Review focuses on advances in diagnostic and outcome tools and their roles in clinical practice and clinical research in patients with polymyositis and dermatomyositis.

Oral pulsed dexamethasone therapy in early rheumatoid arthritis: a pilot study

Pulse therapy with high-dose glucocorticoids (GCs) is widely used as "bridging therapy" for the treatment of patients with active rheumatoid arthritis (RA). Oral pulsed dexamethasone therapy has never been used for this purpose. We determined the clinical efficacy of oral pulsed dexamethasone treatment in patients with early active RA, concomitantly starting with disease-modifying anti-rheumatic drugs (DMARDs). Fourteen early RA patients, glucocorticoid-naive and with active disease for less than 1 year were included. Ten patients were treated with oral pulsed dexamethasone therapy for 4 days in a row. Of this group, four patients received 10 mg dexamethasone/day, three patients 20 mg/day, and three patients 40 mg/day. As controls, four patients were treated with intramuscular methylprednisolone injections. Disease activity (ascertained by disease activity score [DAS]) and biochemical variables were measured at base line, and biweekly thereafter for up to 4 weeks, and monthly thereafter for up to 3 months. A decrease in disease activity, similar in all subgroups, was observed. Nine of 10 patients responded favorably (decrease in DAS of >1.2) 4 weeks after the start of the study. This response was sustained in the months thereafter. One patient did not respond at all, and disease progression during treatment was observed in one patient. No side effects were reported. Only once was a decrease in cortisol level observed; this was at 2 weeks after the start of the study (0.03 micromol/L, reference value 0.18-0.70 micromol/L). Oral pulsed dexamethasone therapy seems to be effective and safe as bridging therapy in early rheumatoid arthritis. The results of the present study justify a long-term controlled trial to compare oral pulsed dexamethasone treatment (10 mg dexamethasone, once weekly for 4 weeks) with the standard GC regimes in the near future.

Life-threatening dermatoses due to connective tissue disorders

Connective tissue disorders such as scleroderma, dermatomyositis and lupus erythematosus are autoimmune, multi-system disorders whose clinical manifestations can be restricted to the skin or may involve many organs. The degree and rate of organ system involvement defer, as does the prognosis and rapidity of disease progression. In this article, scleroderma, dermatomyositis and lupus erythematosus will be reviewed in respect to their life-threatening potential.

Inflammatory myopathies: clinical, diagnostic and therapeutic aspects

The three major forms of immune-mediated inflammatory myopathy are dermatomyositis (DM), polymyositis (PM), and inclusion-body myositis (IBM). They each have distinctive clinical and histopathologic features that allow the clinician to reach a specific diagnosis in most cases. Magnetic resonance imaging is sometimes helpful, particularly if the diagnosis of IBM is suspected but has not been formally evaluated. Myositis-specific antibodies are not helpful diagnostically but may be of prognostic value; most antibodies have low sensitivity. Muscle biopsy is mandatory to confirm the diagnosis of an inflammatory myopathy and to allow unusual varieties such as eosinophilic, granulomatous, and parasitic myositis, and macrophagic myofasciitis, to be recognized. The treatment of the inflammatory myopathies remains largely empirical and relies upon the use of corticosteroids, immunosuppressive agents, and intravenous immunoglobulin, all of which have nonselective effects on the immune system. Further controlled clinical trials are required to evaluate the relative efficacy of the available therapeutic modalities particularly in combinations, and of newer immunosuppressive agents (mycophenolate mofetil and tacrolimus) and cytokine-based therapies for the treatment of resistant cases of DM, PM, and IBM. Improved understanding of the molecular mechanisms of muscle injury in the inflammatory myopathies should lead to the development of more specific forms of immunotherapy for these conditions.

Idiopathic inflammatory myopathy: management and prognosis

We are entering an exciting era in our understanding and management of the connective tissue diseases and, in particular, inflammatory myopathy. There is an established array of immunosuppressive regimens available to clinicians; rehabilitative and physical therapeutic interventions are evolving to provide many nonpharmacologic options to complement current therapy. Our ability to quantify [table: see text] the disease burden, using newly developed tools to distinguish myositis disease activity from disease damage, will allow us to measure with greater sensitivity the effects of treatment interventions. These measures, together with the development of international consensus regarding the standardization of many clinical trial design parameters, will enhance our capacity to conduct well-designed, prospective, multicenter studies of established and newly developed therapies. The explosion of immunopathogenetic information, in conjunction with novel biologic agents (Table 4), will afford investigators a treatment menu with multiple therapeutic options. The continuing challenge for the practitioner is the development of a logical, well-studied, multifaceted, and multidisciplinary holistic approach that optimizes the risk: benefit ratio for each individual patient and uses a rational combination of immunomodulatory agents in conjunction with ancillary measures.

Inflammatory muscle diseases

Dermatomyositis and polymyositis are treatable disorders of skeletal muscle. Despite their clinical similarities, they appear to have fundamentally different autoimmune origins. Inclusion body myositis, from its origins 30 years ago, has emerged as the commonest acquired myopathy of the elderly. Despite inflammatory changes, it is unclear whether it should be considered a primary inflammatory myopathy, and it generally responds poorly to the same treatments that are effective in other inflammatory myopathies.